Cigarette smoking causes cancer, heart disease, stroke, and lung diseases, and is responsible for more than 440,000 deaths per year (CDC, 2008; USDHHS, 2010). Quitting smoking can significantly reduce a person’s risk of morbidity and mortality (Fiore et al., 2008; USDHHS, 2010). While a majority of adult cigarette smokers tried to quit in the past year (52% in 2010), only 32% of these reported using an effective cessation treatment (i.e., counseling and/or medication) (CDC, 2011). Use of other cessation strategies that have not been determined to be efficacious is common, including gradually cutting back on the number of cigarettes smoked, switching to “light” cigarettes, and switching to other tobacco products (Schauer, Malarcher, & Babb, 2013). Currently, tobacco companies are promoting use of other tobacco products as alternatives to smoking cigarettes (Curry, Pederson, & Stryker, 2011; Kozlowski, 2007). The public may view these products as cigarette smoking cessation aids. However, little is known about who reports switching to other tobacco products to quit smoking cigarettes and which tobacco products people report switching to.

While tobacco companies have marketed smokeless tobacco (SLT) as substitutes for cigarettes in a settings where one cannot smoke (Curry et al., 2011), they have not explicitly marketed them as smoking-cessation aids, perhaps due in part to regulatory limitations (Kozlowski, 2007). Few studies have assessed how common or effective switching to SLT to quit smoking cigarettes may be; and many of the published studies on this topic were funded by unrestricted grants from SLT manufacturers (Heavner, Rosenberg, & Phillips, 2009; Rodu & Phillips, 2008; Rodu, Stegmayr, Nasic, & Asplund, 2002; Tilashalski, Rodu, & Cole, 2005). Data from impartial sources do not appear to support anecdotal claims that SLT helps people quit smoking (Tomar, 2007; Tonnesen, Mikkelsen, & Bremann, 2008). Nationally representative data suggest that few cigarette smokers switch entirely from cigarettes to SLT, with most remaining dual users of cigarettes and SLT (Zhu et al., 2009).

Much less is known about whether or not cigarette smokers switch to cigars, pipes, or other combusted tobacco products in an attempt to quit. While per capita cigarette consumption has decreased in the past decade, consumption of non-cigarette combustible tobacco products has increased significantly (CDC, 2012). At least among young adults, some recent data suggest that cigarette and polytobacco users perceive other combusted tobacco products like cigars, cigarillos, or hookah to be less harmful than cigarettes (Latimer, Batanova, & Loukas, 2013). To our knowledge, no studies have assessed whether or not people report switching to other combusted products to quit smoking cigarettes. Furthermore, little is known about the sociodemographic characteristics of those who switch to other tobacco products in an effort to quit smoking cigarettes.

Knowledge of the prevalence and socio-demographic characteristics of smokers who report trying to switch to other tobacco products as a cessation strategy is vital to ongoing research as use of these products increases; findings could also be used for targeted education interventions. Therefore, the purpose of this study is to use nationally representative data to assess the prevalence and correlates of adult cigarette smokers who report switching to SLT (chewing tobacco, snuff, or snus) or to other combusted products (cigars, cigarillos, little filtered cigars, or pipes filled with tobacco) as a cigarette smoking cessation strategy.

Of the total sample of smokers and former smokers who made a quit attempt in the past year, 3.1% reported trying to switch to SLT to quit smoking cigarettes, 2.2% reported trying to switch to other combusted products to quit, and 0.6% (n=68) reported trying both switching strategies to quit. Compared with non-switchers, a higher percentage of those trying to switch to SLT were male (86.1% vs. 51.5%), white (80.3% vs. 72.2%), between ages 18-24 years (26.7% vs. 17.2%), and smoked ≤ 30 minutes after waking (55.2% vs. 57.8%); a lower percentage were black (6.4% vs. 12.1%), age 45 years or older, from the Northeastern region of the U.S., and usually smoked menthol cigarettes (Table 1). About 42.9% of current and former smokers who said they tried to switch to SLT to quit reported current SLT use; 53.0% reported other current tobacco use (Table 1).

Compared with non-switchers, a higher percentage of those switching to other combusted tobacco products were male (70.6% vs. 51.5%), black (20.6% vs. 12.1%), between ages 18-24 years (26.6% vs. 15.7%), smoked ≤ 30 minutes after waking (50.0% vs. 39.5%), reported using counseling resources during their last quit attempt (10.7% vs. 5.3%), and reported using medication during their last quit attempt (36.8% vs. 30.0%); a lower percentage were white (64.9% vs. 72.2%) and age 25-44 years (34.6% vs. 42.0%; Table 1). Differences in the percentage of former cigarette smokers who had quit less than a year ago was similar between non-switchers and those trying to switch to SLT or combusted tobacco.

In multivariable logistic regression models, significant correlates of trying to switch to SLT were being male (AOR=6.0, 95% CI: 4.1, 8.7), between 18-24 or 25-44 years of age (vs. ≥65 years; AOR for 18-24 years=3.9, 95% CI: 2.1, 7.1, AOR for 25-44 years=2.4, 95% CI: 1.4, 4.1), from a region other than the northeast, a current nondaily smoker (vs. current daily; AOR=1.6, 95% CI: 1.1, 2.2), smoking ≤30 minutes after waking (vs. >30 minutes; AOR=1.8, 95% CI: 1.4, 2.4), and using medication during the last quit attempt (AOR=1.4, 95% CI: 1.1, 1.8). Those who were black, non-Hispanic or Hispanic had a lower odds of reporting trying to switch to SLT compared to white, non-Hispanic participants (AOR=0.4, 95% CI: 0.2, 0.8, and AOR=0.6, 95% CI: 0.4, 0.9, respectively).

Correlates of trying to switch to other combusted products were being male (AOR=2.2, 95% CI: 1.6, 2.9), being black (vs. white; AOR=1.9, 95% CI: 1.2, 2.9), being age 18-24 years (vs. ≥65 years, AOR=2.4, 95% CI: 1.3, 4.5), smoking ≤30 minutes after waking (vs. >30 minutes; AOR=1.5, 95% CI: 1.2, 2.0), and using counseling and medication during the last quit attempt (AOR=2.0, 95% CI:1.3, 3.0, and AOR=1.4, 95% CI:1.1, 1.9, respectively).

This study is among the first to attempt to characterize adult smokers who report trying to switch to SLT or to other combusted products as a cessation strategy. Comparing these data to other national surveillance data, it appears that switching to other tobacco products may be as common as use of counseling for cessation [e.g., 5.9% prevalence for switching vs. 5.9% prevalence for counseling use (CDC, 2011)].

Findings suggest that those attempting to switch to other tobacco products to quit smoking cigarettes are predominately male. State and national use data indicate that men are more likely to use other tobacco products (CDC, 2010). While findings suggest that being white, non-Hispanic is a significant correlate of trying to quit by switching to SLT, being black, non-Hispanic was a significant correlate of trying to quit by switching to other combusted products. This may be due to targeted marketing and decreased pricing of cigars, cigarillos, and little cigars in predominately African-American neighborhoods (Cantrell et al., 2013). Being a young adult (age 18-24 years) was associated with switching to SLT and switching to other combusted products, and being a current nondaily smoker was associated with switching to SLT to try to quit. These groups may also be targeted by tobacco company marketing to try non-cigarette tobacco products (Dave & Saffer, 2013).

The percentage of former cigarette smokers quit <1 year was not significantly different across groups, and being a former smoker was not associated with using either switching strategy. A more robust sample size is needed to assess whether or not those who try to switch from cigarettes to other products are successful in quitting cigarettes or remain dual users. Longitudinal research is needed to better assess how switching to other tobacco products to attempt to quit cigarettes impacts dual and polytobacco use over time.

The finding that using counseling during the last quit attempt was significantly associated with trying to quit by switching to other combusted products is concerning in that recommended counseling strategies should provide education on effective strategies to quit (Fiore et al., 2008). More research is needed to determine if counseling preceded, followed, or occurred concurrently with an attempt to switch to another tobacco product to quit. Current evidence does not suggest that switching to either SLT or other combusted products is an effective approach (Tomar, 2007; Tonnesen et al., 2008; Zhu et al., 2009); health professionals should encourage those interested in quitting to use evidence-based strategies, as outlined by the U.S. Public Health Service Guidelines on Treating Tobacco use and Dependence (Fiore et al., 2008).

This study is subject to a number of limitations. First, data are cross-sectional, and therefore no causal inferences can be drawn between reported cessation approaches and patterns of tobacco product use. Second, data are self-reported, and are subject to recall and social-desirability biases. Third, we were limited by the surveillance questions, and were unable to analyze data separately by specific SLT products or combusted products (e.g., by snus users, chewing tobacco users, etc.). Thus, we cannot attribute specific characteristics to use of specific products for cessation, nor can we tell which products people were using in their cigarette cessation attempt. Furthermore, this particular surveillance system did not yet include electronic cigarettes. Finally, we do not have data on the trajectory and sequence of dual or polytobacco use. Did individuals begin by using multiple tobacco products and subsequently try to quit cigarette use while continuing to use other products? Or did they shift from exclusively smoking cigarettes to initiating use of non-cigarette tobacco products in an attempt to quit? Future studies should seek to provide more granular descriptions of socio-demographic characteristics and types of tobacco products used in order to better inform development of health education campaigns and other interventions.

Despite these limitations, this study provides important information about the types of smokers who may be utilizing these two cessation strategies. These data can be used to strengthen tobacco education, cessation, and control efforts and to further understand attempts by certain demographic groups to minimize harm from cigarette smoking.